The role of invasive hemodynamic evaluation and pump optimization in the management of patients supported with left ventricular assist devices (LVAD)

Despite improved outcomes, LVAD patients still present with frequent rehospitalizations, including those for heart failure (HF). The aim of this study was to investigate the changes in hemodynamic parameters after LVAD implant and the role of hemodynamic optimization obtained by the invasive ramp test (RT) in improving survival and reducing HF admissions. We enrolled patients implanted with centrifugal pumps between 2013 and 2024 who underwent post-implant right catheterization (RHC) during the index hospitalization. Optimal hemodynamics were defined as a right atrial pressure < 10 mmHg, pulmonary capillary wedge pressure < 15 mmHg, and cardiac index > 2.2 l/min/m2. The endpoint was survival free from HF admission according to the hemodynamic profile at 24 months. 63 patients were included in the study. After the implant there was a significant improvement in pulmonary pressure and a reduction in the indices of right ventricular function without changes in central venous pressure. 41% of the patients already had an optimal hemodynamic profile, while 14% achieved it after RT. At 24 months, survival free from HF admission was significantly reduced in patients with non-optimized profiles (81 vs. 58 %, OR 3.2 [1.2-8.2], p = 0.01). This difference was not significant when the effect of the ramp test was not considered (p=0.07). In patients with LVAD, survival free from HF admissions was significantly higher in those with optimized hemodynamics, and RT provided the opportunity to further improve hemodynamic profiles. The non-optimized profile was an independent predictor of mortality and hospitalization for HF.